Alcohol Use Disorder in Adults

ICD-10 codes: Mild F10.10; Moderate to severe F10.20

Alcohol use disorder (AUD) is part of a cluster of often co-occurring diagnoses called the substance-related and addictive disorders. Substance use disorders are a group of psychiatric conditions that include:

Tobacco use disorder
Cannabis use disorder (i.e., marijuana)
Stimulant use disorder (e.g., cocaine, crack, methamphetamine, amphetamines)
Opioid use disorder (e.g., heroin, prescription painkillers)
Hallucinogen use disorder (e.g., LSD, PCP, ecstasy/MDMA, psilocybin)

These disorders are characterized by recurrent use of alcohol and/or other substances that causes significant impairment, such as health problems, disability, and failure to meet responsibilities at work, school, or home. Individuals with substance use disorders have difficulty controlling their intake of alcohol or other drugs, trouble with social functioning, risky use and/or use that leads to risky situations, and pharmacological changes such as increased tolerance to alcohol and drugs and symptoms of withdrawal when they do not use substances. In addition, individuals with substance use disorders find it is very difficult to change their substance use despite negative consequences of their use and the desire to make changes. The severity of a substance use disorder - mild, moderate, or severe - is based on the number of criteria met.

What is alcohol use disorder?

AUD is a psychiatric disorder that affects approximately 7% of adults in the United States. AUD is a problematic pattern of alcohol use leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period:

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Alcohol is often taken in larger amounts or over a longer period than was intended.
There is a persistent desire or unsuccessful efforts to cut down or control alcohol use.
A great deal of time is spent in activities necessary to obtain alcohol, use alcohol, or recover from its effects.
Craving, or a strong desire or urge to use alcohol.
Recurrent alcohol use resulting in a failure to fulfill major role obligations at work, school, or home.
Continued alcohol use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of alcohol.
Important social, occupational, or recreational activities are given up or reduced because of alcohol use.
Recurrent alcohol use in situations in which it is physically hazardous.
Alcohol use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by alcohol.
Tolerance, as defined by either of the following: a) A need for markedly increased amounts of alcohol to achieve intoxication or desired effect b) A markedly diminished effect with continued use of the same amount of alcohol.
Withdrawal, as manifested by either of the following: a) The characteristic withdrawal syndrome for alcohol, and b) Alcohol (or a closely related substance, such as a benzodiazepine) is taken to relieve or avoid withdrawal symptoms.

It is common that individuals with AUD experience difficulties in many areas of life - such as failing to get to work on time due to a hangover, not remembering to pick up a child from school because they were intoxicated, or missing social events due to a desire to hide alcohol use. AUD is also associated with increases in other dangerous behaviors such as driving under the influence and risky sexual behaviors due to impaired judgment. In addition, in severe cases, withdrawal from alcohol can be extremely dangerous and should be monitored by a physician.

Understanding Alcohol Use Disorder and the related problem of binge drinking

Many people begin drinking at a young age. Slightly more than half of Americans (56%) report drinking alcohol in the past month, while about a quarter (25%) report binge drinking in the past month.

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Definitions for different levels of drinking are listed below. There are typically different guidelines for men and women, as women are more sensitive to alcohol's effects than men:

Moderate Drinking:
- Women: Up to 1 drink per day
- Men: Up to 2 drinks per day
Binge Drinking:
- Women: 4 or more alcohol drinks over a 2 hour period
- Men: 5 or more alcoholic drinks over a 2 hour period
Heavy Drinking: Drinking 5 or more drinks on the same occasions on each of 5 or more days in the past 30 days.

If an individual is a binge drinker and/or a heavy drinker, it is possible they may have an AUD. However, AUD is possible even without drinking above these limits, as people differ in how sensitive they are to alcohol's effects and what constitutes problematic use of alcohol.

AUD can range from mild to severe. In severe cases, AUD can result in liver damage or death. Nearly 88,000 people die from alcohol-related causes annually, making it the third leading preventable cause of death in the United States. Alcohol use also contributes to over 200 diseases and injury-related health conditions, most notably AUD, liver cirrhosis, cancers, and injuries.

Many people with AUD also have other psychiatric conditions, such as other substance use disorders, mood disorders, anxiety disorders, schizophrenia, and/or post-traumatic stress disorder.

Alcohol use disorder is characterized by changes in brain function caused by repeated use and withdrawal over time. These neuroadaptations are believed to occur in brain areas responsible for emotional responses including stress, reward processing, and executive function. In addition, neuroadaptations are thought to relate to AUD symptoms such as loss of control over alcohol use, continued use despite negative consequences, and giving up important activities in order to use alcohol. Genetics have also been shown to be a risk factor for the development of an AUD, so if someone in your immediate family has an AUD, you may be at increased risk.
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Acute Effects of Alcohol

Alcohol is classified as a depressant, which slows down vital functions (resulting in slurred speech, unsteady movement, disturbed perceptions and an inability to react quickly). Alcohol has significant impact on the mind, reducing the ability to exercise normal judgment and think rationally. Although considered a depressant, when consumed in small to moderate quantities, alcohol may produce stimulant effects. Many people find that initially, alcohol may help them to "loosen up" in social situations; over time, however, with heavier and/or problematic use, depressant effects of alcohol can become more prominent.

How is alcohol use disorder treated?

The Substance Abuse and Mental Health Services Administration and National Institutes on Alcohol Abuse and Alcoholism suggest that the following behavioral treatments have been found effective:

Cognitive-Behavioral Therapy: This treatment can take place in individual therapy or in groups. It focuses on identifying feelings and situations ("cues") that lead to heavy drinking, as well as managing stress that can lead to relapse. The goal is to change the thought processes that lead to excessive drinking and to develop the skills necessary to cope with everyday situations that might trigger problem drinking. Under the umbrella of CBT, contingency management uses immediate and tangible reinforcements for positive behaviors to modify problematic behaviors such as alcohol use.
Motivational Enhancement Therapy: This treatment is conducted over a short period of time to build and strengthen motivation to change one's drinking behavior. The therapy focuses on identifying pros and cons of seeking treatment, forming a plan for making changes in one's drinking behavior, building confidence, and developing the skills needed to stick to the plan.
Marital and Family Counseling: This treatment incorporates spouses and other family members and can play an important role in repairing and improving family relationships that have often been damaged by alcohol use. Studies show that strong family support through family therapy increases the chances of maintaining abstinence (avoiding alcohol), compared with patients undergoing individual counseling only.
Brief Interventions: These treatments are short, one-on-one or small-group counseling sessions that are time-limited. The counselor provides information about the individual's drinking pattern and potential risks. After receiving personalized feedback, the counselor will work with the client to set goals and provide ideas for helping to make changes.
12 Step Facilitation Therapy: This treatment seeks to guide and support engagement in 12-step programs such as Alcoholics Anonymous.
Intensive Outpatient Programs: These programs may combine individual and group therapy components using approaches mentioned above, peer support, and may include other monitoring services such as breathalyzer and/or urine toxin screenings. Intensive outpatient programs typically involve attending several sessions or classes per day for most of the day, for up to several weeks. The structure of these programs can help people avoid using alcohol or other drugs, in addition to helping to build coping skills to avoid further use.
Inpatient and Residential Substance Use Treatment: These programs typically involve a stay at a hospital or other treatment facility, utilizing several of the treatment modalities mentioned above. Like intensive outpatient programs, the structure of residential treatment programs help individuals to avoid using alcohol by removing them from tempting environmental cues and stressors that may lead them to drink while new skills and behaviors are learned and developed. Residential treatment is considered a higher level of care than regular outpatient or intensive outpatient treatment.
Aftercare: After completing residential substance use treatment, involvement in aftercare programs involving monitoring, skill bolstering, and relapse prevention, can lead to better outcome.

In addition, the U.S. Food and Drug Administration (FDA) has approved three medications for treating alcohol dependence.

Naltrexone can help people reduce heavy drinking.
Acamprosate makes it easier to maintain abstinence.
Disulfiram blocks the breakdown (metabolism) of alcohol by the body, causing unpleasant symptoms such as nausea and flushing of the skin. Those unpleasant effects can help some people avoid drinking while taking disulfiram.In addition, the U.S. Food and Drug Administration (FDA) has approved three medications for treating alcohol dependence.

It is important to remember that not all people will respond to medications, but for a subset of individuals, they can be an important tool in overcoming alcohol dependence. Other medications are currently being tested for effectiveness for treating AUD.

Additional Treatments to Consider

Preliminary evidence suggests that the following strategies, while not a substitute for the more well-validated treatments described above, might be considered.

Social support through Alcoholics Anonymous and/or other self-help groups
Exercise as an adjunct to reduce alcohol cravings
Short term tangible reinforcement (e.g. collecting money that would normally be used to purchase alcohol or alcohol related products, and saving it to purchase a reward for quitting).